Adopting Risk Adjustment as a Pathway to Improve Health Outcomes Post-COVID

Healthcare utilization plummeted immediately and discernably in early 2020, almost entirely due to consumer and provider concerns about COVID transmission. From March to mid-July 2020, 52% of the 1,055 respondents in a Johns-Hopkins University COVID-19 Civic Life and Public Health Survey admitted to delaying care due to concerns about transmission. Not unrelated, and not surprisingly, the Medical Group Management Association found that Covid-19 had a negative financial impact on 97% of the 724 medical practices it surveyed.

Care delay and care avoidance were costly to health plans over the past two years, especially to risk- and value-based care health plans. COVID-related deaths diluted risk scores, leading to reduced reimbursements for the 2021 plan year and confounding the process of projecting care costs in 2022.

As we begin to return to a new normal, how can health plans and providers offset some of their losses and prepare for future COVID waves? Some answers lie in the confluence of risk adjustment and quality management.

The Value of Risk Adjustment to Quality in the Post-Pandemic Landscape

Risk adjustment is a methodology that adjusts plan payments based on members' health status, removing penalties for patient and population risk factors. But several waves of high COVID transmission in 2020 and 2021 caused immediate and necessary reductions in the availability and utilization of non-COVID related healthcare that still have not yet fully rebounded.

As a result, early diagnosis and treatment opportunities have been missed, and diseases have progressed in the absence of ongoing care management. Now, providers are scrambling to prioritize and address backlogged care needs and often diagnosing conditions in later, less easily treatable stages that require costlier care. Delayed care also introduces payment dissonance for health plans and providers in value-based arrangements. Costs must be paid upfront, but risk adjusted revenue is paid the following year. 

Closing gaps in care is at the heart of quality care delivery. And as a plan’s understanding of its at-risk members and populations grows, its opportunities to improve care delivery also expand. It relies on the transparent and actionable care need intelligence that risk adjustment methodology provides.

Because the heart of risk adjustment lies in the capture and analytics of timely, accurate and robust patient data, it holds the key to improving care quality by identifying opportunities to close the care gaps fueled by COVID-19 before members’ conditions worsen further. And it provides a means to pay for needed member care. For this reason, a robust set of risk adjustment analytics tools that works in harmony with quality improvement goals is an absolute must for any plan seeking to get back on track with preventive care and care management and recovering revenue loss in the wake of COVID-related care avoidance.

Data Informed Risk Adjustment is Critical to Post-COVID Care Management

Avoiding (or at least mitigating the impact of) the high cost of avoided and delayed care comes down to identifying and prioritizing care for high-need patients while maintaining the current health of all members. By allocating resources according to the member’s current care needs, plans and providers can also significantly reduce costs by preventing and/or slowing the need for costlier care down the road. And this, in turn, improves outcomes through preventive care, early intervention and care management.

But all of this is next to impossible in today’s healthcare landscape without reliable, accurate, timely, actionable real-time data capabilities that reveal which members are most in need of preventive care and early care management interventions.

Vital Data Technology's Affinitē Risk Adjustment solution provides real-time reporting and streamlined chart retrieval, coding and encounters submission processes that ease the data submission burden on providers while also giving payers and providers the insights they need to prioritize engagements and interventions.

It works seamlessly on the Affinitē platform alongside Affinitē Quality Improvement and Management to increase transparency and interoperability between risk adjustment and quality teams and deliver higher ROI – even in a complex healthcare landscape made more complicated by the pandemic.

If you have any questions about this article or want to learn more, click below to talk with one of our Risk Adjustment experts.